IMPORTANCE Although opioids are used to treat neonatal abstinence syndrome (NAS), the best pharmacologic treatment has not been established. OBJECTIVE To compare the safety and efficacy of methadone and morphine in NAS. DESIGN, SETTING, AND PARTICIPANTS In this randomized, double-blind, intention-to-treat trial, term infants from 8 US newborn units whose mothers received buprenorphine, methadone, or opioids for pain control during pregnancy were eligible. A total of 117 infants were randomized to receive methadone or morphine from February 9, 2014, to March 6, 2017. Mothers who declined randomization could consent to data collection and standard institutional treatment. INTERVENTIONS Infants were assessed with the Finnegan Neonatal Abstinence Scoring System every 4 hours and treated with methadone or placebo every 4 hours or morphine every 4 hours. Infants with persistently elevated Finnegan scores received dose increases. Infants who exceeded a predetermined opioid dose received phenobarbital. Dose reductions occurred every 12 to 48 hours when signs of NAS were controlled with therapy, stopping at 20% of the original dose. MAIN OUTCOMES AND MEASURES The primary end point was length of hospital stay (LOS). The secondary end points were LOS attributable to NAS and length of drug treatment (LOT). RESULTS A total of 183 mothers consented to have their infants in the study; 117 infants required treatment. Because 1 parent withdrew consent, data were analyzed on 116 infants (mean [SD] gestational age, 39.1 [1.1] weeks; mean [SD] birth weight, 3157 [486] g; 58 [50%] male). Demographic variables and risk factors were similar except for more prenatal cigarette exposure in infants who received methadone. Adjusting for study site and maternal opioid type, methadone was associated with decreased mean number of days for LOS by 14%

Many of the MIC changes observed could potentially impact the health of term and preterm infants. Further research is warranted.

Breastfeeding is the recommended feeding method for infants. The decision to allow women to breastfeed while consuming alcohol and other drugs postpartum presents a problem for the health care provider. This article discusses the biochemical properties of various drugs as they relate to breastfeeding. Women in a methadone treatment program should be allowed to breast feed; however, more research is needed to determine the efficacy of breastfeeding when women are receiving buprenorphine. Breastfeeding should not be recommended in women who abuse heroin recreationally until more information is known about the actual amount of morphine present in the breast milk.

Nationally, there has been a steady increase in the number of infants born with neonatal abstinence syndrome or drug withdrawal. Many of these infants remain in the hospital because their signs of withdrawal require pharmacologic management. The length of hospital stay can range from 1 week to several months depending on the severity of withdrawal. One way to decrease the length of stay and reduce the cost of care is to discharge the infant from the hospital sooner. To discharge infants sooner, their neonatal abstinence syndrome must be accurately assessed so that appropriate pharmacologic management can be administered. One way to increase the accuracy of assessing withdrawal signs is to implement an interobserver reliability protocol. This approach will allow healthcare professionals to gain consistency and accuracy in assessing infants for signs of withdrawal that may facilitate earlier discharge from the hospital.

The results suggest that the use of a mechanical rocking bed may be overstimulating for these fragile infants during the acute period of withdrawal.